Cardioneuroablation as Therapy to Neurally Mediated Bradycardia
Yan Yao MD, PhD, FHRSArrhythmia Center
Fuwai Hospital, Peking Union Medical College-Chinese Academy of Medical Sciences
National Center for Cardiovascular Diseases
Beijing, China
Background
• Reverse remodeling of sinus node function after catheter ablation of atrial fibrillation in patients with prolonged sinus pauses and/or sinus bradycardia has been observed since 1995.
• The increasement of sinus rate post PV isolation of paroxysmal AF may last 1 year.
• Cryo-PVI causes a significant rise of sinus rate that is more pronounced in subjects with previous sinus bradycardia.
Circulation. 2003;108:1172-1175
Europace 2005 415–420
Circulation. 2003;108:1172-1175
Clin Res Cardiol. 2021
GPs of the left atrium
PA
1.0
cm
LCT
HFS (+ )Vagal ResponseHFS (–)Vagal Response
RSPV
RIPV
RAO
LAA
MVAInferior Left
GP
Anterior Right GP
Inferior RightGP
Superior LeftGP
RSPV
GPs Distribution
Po S, 2009 Autonomic Neuroscience: Basic and Clinical 199 (2016) 3–16
Anatomic Locations of Ganglionated Plexus (GPs)
Corradi D et al. Int J Cardiol 2013;168:1769-78.
⚫ Tissues between LA and pulmonary veins
⚫ Tissues between RA and SVC / IVC
⚫ Interatrial tissues
⚫ Marshall vein
⚫ CS
⚫ Tissues adjacent to coronary arteries
⚫ Interventricular tissues
Concept of Cardioneuroablation
The GPs could be abolished by catheter ablation
It may rebalance the due to the physiological function of GPs’ and also
anatomical location which can be targeted easily by ablation catheter.
Potential Indications:
⚫Vasovagal syncope (VVS)
⚫Brady arrhythmias
⚫Atrial fibrillation
• Anatomic
• EGM Mapping
• High Frequency stimulation(HFS)
Europace, 14 (2012),
pp. 528-606
Po S, JCE 2009
Methods for GPs Targeting
Anatomic targets of GPs
LSGP
RAGP
LLGP
LIGPRIGP
CSmGP
Methods for Targeting: 1
Jose Carlos Pachon (Brazil): RA + LA
Europace (2011) 13, 1231–1242
Methods for Targeting: 2
Esteban W. Rivarola (Brazil): RA + LA
Circ Arrhythm Electrophysiol. 2017 Feb;10(2):e004638.
Methods for Targetting: 3
Tolga Aksu (Turkey): RA + LA
Pacing Clin Electrophysiol. 2016 Jan;39(1):42-53
J Cardiovasc Electrophysiol 2020 Dec;31(12):3326-3329.
Methods for Targeting: 4
Philippe Debruyne (Belgium): RA
Circ Arrhythm Electrophysiol 2018;11:e006604
RAGP
LSGP
LIGP RIGP
RAGP RIGP
LSGPLLGP
LIGP
⚫ RAGP: Right anterior GP
⚫ LSGP: Left superior GP
⚫ LIGP: Left inferior GP
⚫ LLGP: Left lateral GP
⚫ RIGP: Right inferior GP
Yan Yao (China): LA
Method for Targeting:High Frequency Stimulation (HFS)
High frequency stimulation (HFS):
Frequency: 20-50HzOutput: 10-150VPW: 10msDuration:2-5 Sec.Positive HFS:SR decrease>50%, sinus pause or AVB>2.0 Sec.
Po SS. J Cardiovasc Electrophysiol. 2009;20:1186-1189
• Deceleration capacity(DC) is derived by PRSA(phase-rectified signal averaging) technique;
• Quantitative assessment of cardiac vagal tone;
• Risk stratification evaluation in AMI patients;
• DC:✓Overall DC(ODC):24 h✓Daytime DC(DDC):6:00-23:00
✓Nighttime DC(NDC):23:00-06:00
Value of Deceleration Capacity (DC)
1. Bauer A. Physica A. 2006;364:423-434.
2. Bauer A. Lancet. 2006;367:1674-1681.
DC > 7.5 could be used to diagnose VVS & increased vagal tone
Zheng LH, Yao Y, et al. Circ AE, 2020
Long-term Effectiveness of Cardioneuroablation in VVS
with HFS vs Anatomic Targeting
Sun W, …Yao Y, et al. JAHA 2016
Underlying Mechanism:
Role of RAGP in Cardioneuroablation
Role of RAGP in Cardioneuroablation
115 consecutive VVS patients (retrospective study)
Hu F, …Yao Y, et al. Heart Rhythm 2019
Ablation sequence: LSGP - LIGP - RIGP - RAGP
Long-term Effectiveness on Hear Rate
3 months 12 months 24 months
Hu F, …Yao Y, et al. Heart Rhythm 2019
GPs Ablation as therapy to Sinus Bradycardia
RAGP as the first target may suppress VR during AF ablation
Hu F, Yao Y, et al, Circulation:AE. 2019
Unifocal Right-Sided RAGP Ablation
Debruyne P, Circ AE. 2018 Sep;11(9):e006604
Patients Selection
• Assessment of the contribution of parasympathetic system:
• Atropine Test: 0.04 mg/kg I.V. for 15 min. An increase of ≥25% or sinus rate ≥90 bpm in the first 15 min is considered as a positive response
• Deceleration Capacity (DC): ≥ 7.5 indicates high vagal tone;
• (For AVB, EP study, adenosine and atropine are all helpful to exclude the intrinsic or extrinsic AVB)
• Contraindications:• Patients with underlying heart disease, especially with heart failure;• Patients with severe hypertension, diabetes or any disease which require β blocker;
Discrimination of intrinsic SSS or AVB from those with high vagal tone
Cardioneuroablation in the treatment of vagal
mediated bradycardias
◆ 38 patients (2017.12-2020.01)
intermittent advanced AV block (AVB):25 (65.8%)
intermittent sinus arrest (SA):11 (28.9%)
symptomatic related sinus bradycardia (SB):7 (18.4%)
Atropine test and DC performed,No vasovagal syncope or AF
Baseline Characteristics of Patients (n﹦38)
Age( year) 36.1±15.3
Sex, Male, n (%) 20 (52.6%)
Follow up time (month) 30.6±23.5
HUT result
Only heart rate decreased, n (%) 7 (18.4%)
Only blood pressure decreased, n (%) 3 (7.9%)
Both heart rate and blood pressure decreased, n (%) 28 (73.7%)
Left atrium diameter (mm)
Left ventricle diameter (mm)
Left ventricular ejection fraction (%)
31.4±4.5
47.1±4.3
64.1±3.8
Clinical outcomes
◆ 30 participants had no recurrence of any types of bradycardiac arrhythmia
◆ 8 patients had recurrent bradycardiac arrhythmias
◆ Only 2 participants accepted pacemaker implantation during follow-up
Recurrent cases:2 pts with AVB; 1 with SA; 1 with SB; 1 with AVB+SA+SB; 2 pts with AVB+SA; 1 with SA+SB;
Unpublished data
Case
33 y, Female,
recurrent syncope (intermittent sinus arrest , frequent junctional escape rhythm )
DC: 30
Baseline
SNRT: 2.3s;
AH 97ms;
HV 77ms
Before Cardioneuroablation After Cardioneuroablation
SANRT (s) 2.3 1.174
AH (ms) 97 93
HV (ms) 77 70
AVN Wenckebach (ms) 480 380
AVNERP (ms) 1000/300 800/280
Summary
◆ Cardioneuroablation may effectively modify the bradycardic arrhythmias caused by hyper vagal tone, which should be confirmed by atropine or DC test;
◆ RAGP is the only targeted GP to increase heart rate and may achieved from both RA & LA approaches;
◆ The indications, methods and endpoints need to be established by further studies.
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